Provider Demographics
NPI:1730622739
Name:SHETTI, KOSHA (PSYD)
Entity type:Individual
Prefix:
First Name:KOSHA
Middle Name:
Last Name:SHETTI
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8202 RIDGELEA ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75209-2624
Mailing Address - Country:US
Mailing Address - Phone:214-558-7474
Mailing Address - Fax:
Practice Address - Street 1:8202 RIDGELEA ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75209-2624
Practice Address - Country:US
Practice Address - Phone:214-558-7474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-22
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36139103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical